Critically important whole school health promotion work has to be sustained: Shifting from program thinking to system thinking Penny Hawe Population Health Intervention Research Centre University of Calgary , Canada www.ucalgary.ca/PHIRC phawe@ucalgary.ca

1. Critically important whole school health
promotion work has to be sustained:
Shifting from program thinking to
system thinking
Penny Hawe
Population Health Intervention Research Centre
University of Calgary , Canada
www.ucalgary.ca/PHIRC
phawe@ucalgary.ca
A CIHR Centre for Research Development in Population Health

2. Take home message
Most effective HP programs seem to be those
that harness dynamic properties of systems
We may be able to use these insights to design
and sustain more effective interventions
Implications are wide ranging (but not too
scary!)

3. Eras of health promotion
1970s and 80s
Testing phase
1990s
Sustainability phase
Early 2000s
Systems phase

5. Prevention Studies, Implementation Findings
Battish et al (1996) 33% of schools implemented
the program properly
Rohrbach et al (1993) 79% teachers omitted
program components
Taggart et al (1990) 45% teachers implement
properly
Flannery et al(1993) 67% teachers miss key
components
Dulak JA, J Prev & Intervention in the Community 1998;17:5-18

6. Evidence on what gets sustained
Proven effective
Consumer and practitioner involvement
$ or in-kind support from outset
Stable, mature host organisation
Compatible mission between host and program
Integrated, not run as separate unit
Financially viable
High level champion

7. Prevention Studies, Implementation Findings
Battish et al (1996) 33% of schools implemented
the program properly
Rohrbach et al (1993) 79% teachers omitted
program components
Taggart et al (1990) 45% teachers implement
properly
Flannery et al(1993) 67% teachers miss key
components
Dulak JA, J Prev & Intervention in the Community 1998;17:5-18

8. 12

9. Look inside the “black box” of the program
to understand more about it and the
change processes going on in and around
it
Started to gain more appreciation of the
schools, in built capacity of “the agents”,
8

10. A tale of two projects
Hutchinson Smoking Prevention Project
(USA)
Gatehouse Project (Australia)
8

11. 5

12. 6

13. Gatehouse Project
26 Australian metro and rural high schools
A collaborative intervention to improve social
environment at school
Randomised controlled trial
Centre for Adolescent Health , University of Melbourne

14. Gatehouse Project – Organisational
Development over 2 years
Entry
Survey, interviews
Feedback
Priority setting
Actions
Implementation
Evaluation
Action team (staff, students, parents)
Part time facilitator
Curriculum
Professional development

15. Towards a more positive social environment
(Patton G, Bond L, Butler S, Glover S)
Classroom Whole school
Security Security
• clear and agreed class rules • implementation and monitoring of
• no put-downs victimisation prevention strategies
• maintaining privacy Communication
Communication • moving towards organisational
• promoting listening to others change
• promote opportunities for one- • peer support program –
on-one interaction with
teachers coordination and training
• physical layout of classroom • student-teacher engagement
• small group work outside of class eg mentoring
Positive regard through Promote participation
participation • organisational change to allow
• part of the group and have student representation
something to contribute • promotion of extra-curric. activities
• promote acknowledgment of • create opportunities for feedback to
others contribution and work students (and teachers)

16. The Gatehouse Project: changes in health
risk behaviour in year 8 students after 2
years
120
100
80
% of group
Comparison schools
60
Intervention
40
20
All analyses
0 adjusted for
Smoking Regular Binge Cannabis Weekly previous level of
smoking drinking Cannabis
substance use in
the school

17. Key milestones
2001 Whole school mental health promotion
symposium, Calgary
2002 - 2004
CORE high school
pilot

18. Social network analysis is the study of social
structure.
It maps relations among people (or organisations)
A person‟s position in a structure determines the
opportunities or constraints that the person will
encounter
-information,
- help
-viewpoints
-approval/disapproval
- affirmation of worth

20. The basics
Nodes, actors
Ties - role based (eg brother of, boss of)
-cognitive, affective (eg., likes, knows)
- actions (eg., talks to, plays with)
Density and centrality

21. School Staff and Teacher Network
Survey (complete network n=50)
Assessed - knowing by name
- regular conversations
- knowing more personally
- advice seeking
- socialising
Twice. At the start, and one year after the
intervention.

22. Staff. Advice seeking a year ago

23. Staff. Advice seeking now

24. Density of relationships, before and after (%)
Before After
Knowing by name 66 95
Knowing more personally 29 39
Regular conversations 26 41
Seeking advice 15 21
Socialising with 6 8

25. Insight
Maybe this is the „real magic „ of the
intervention
Maybe explains why it`s easy to do things
in some places and harder in others
Led to workplace-focused school
improvement work in CORE as essential
first step

26. Students. The talk-to-when-upset network at Time 1
One elementary classroom

27. Students. The talk-to-when-upset network at Time 2,
same class

28. Play at school together, grade 6, baseline assessment
coded by typical peer rated behaviour

29. Key milestones in the transfer
2001 Whole school mental health promotion
symposium, Calgary
2002 - 2004
CORE high school
pilot 2004-2008 4 elementary and
Stronger one junior high
teacher/workplace
focus
Extended social network
analysis into the students
2009/2010 CORE final pilot
(elementary)
Added a cortisol assessment
Launched an RCT in 2010/2011

30. A tale of two projects
Hutchinson Smoking Prevention Project
(USA)
Gatehouse Project (Australia)
8

31. A tale of two projects
Goliath versus David?
Individual versus system?
Controlled versus flexible?
Unlucky versus lucky?
8

32. More about contexts
É

33. Contextual turbulence in a whole-school
health promotion project
over four years
School School School School
1 2 3 4
Change in principal 1 0 6 1
Change in vice vacant 2 2 1
principal
Staff turnover 43% 35% 74% 59%
Student turnover 65% 41% 59% 27%
Omstead et al. Advances in School Mental Health
Promotion 2009

35. Thinking of my teachers this term,
I really like……..
All of them 14%
Most of them 42%
Half of them 16%
One or two 25%
None of them 3%
13

36. Implications of moving from program
thinking to system thinking
1. Can‟t activate and draw on what each part has
to give if a system not interconnected in first
place – social health groundwork
2. Start where they are at (fix lights in the toilets)
3. Don‟t just offer your favourite program – help
sort, choose, add and take away
4. Recognise the function played by “useless”
programs

37. DARE Drug Abuse Resistance Education
• 33 million children 1983-1997, no evidence of
effectiveness
• Costly. Average of $217-$334 per child per year
• Renovated at cost of $13.7m, still not known if
effective

39. Implications of moving from program
thinking to system thinking
5. Give more power to school to choose but
regulate the quality of the HP offerings
including those in non profit and voluntary
sector

41. Implications of moving from program
thinking to system thinking
5. Give more power to school to choose but
regulate the quality of the HP offerings
including those in non profit and voluntary
sector
6. Measure background contextual change

43. Incidental references to smoking in Calgary Herald
and Edmonton Journal, over a 3 year period
60
May-01 Apr-02 Jan-03
50
40
30
20
10
0
incidental - as an entertainer/sports incidental - other than entertainment

44. Implications of moving from program
thinking to system thinking
5. Give more power to school to choose but
regulate the quality of the HP
offerings, including those in non profit and
voluntary sector
6. Measure background contextual change
7. Increase feedback about performance
8. Reward evaluation regardless of results
9. Widen what is measured (including cost)

45. Implications of moving from program
thinking to system thinking
10.Sustain, invest, expand, mainstream
11. Prompt others to care – public demand and
accountability as a new system driver for health
promotion
....”My School”